SCORE Study report #11: incidences of neovascular events in eyes with retinal vein occlusion

Analyzing the changing trend of corneal biomechanical properties under different influencing factors in T2DM patients

To analyze the changing trend of CH and CRF values under different influencing factors in T2DM patients. A total of 650 patients with T2DM were included. We discovered that the course of T2DM, smoking history, BMI, and FBG, DR, HbA1c, TC, TG, and LDL-C levels were common risk factors for T2DM, while HDL-C levels were a protective factor. Analyzing the CH and CRF values according to the course of diabetes, we discovered that as T2DM continued to persist, the values of CH and CRF gradually decreased. Moreover, with the increase in FBG levels and the accumulation of HbA1c, the values of CH and CRF gradually decreased. In addition, in patients with HbA1c (%) > 12, the values of CH and CRF decreased the most, falling by 1.85 ± 0.33 mmHg and 1.28 ± 0.69 mmHg, respectively. Compared with the non-DR group, the CH and CRF values gradually decreased in the mild-NPDR, moderate-NPDR, severe-NPDR and PDR groups, with the lowest CH and CRF values in the PDR group. In patients with T2DM, early measurement of corneal biomechanical properties to evaluate the change trend of CH and CRF values in different situations will help to identify and prevent diabetic keratopathy in a timely manner.

The progress of assessment methods and treatments of neovascular glaucoma secondary to central retinal vein occlusion

Neovascular glaucoma is a condition that results from central retinal vein occlusion and often leads to blindness. Accurate evaluation and appropriate treatment are crucial for patients. However, there is currently no uniform and clear standard to differentiate between ischemic and non-ischemic central retinal vein occlusion. Also, the assessment of neovascular glaucoma progression is uncertain. Meanwhile, although pan-retinal photocoagulation is a standard treatment to prevent the onset of neovascular glaucoma, its actual efficacy and the timing of intervention remain highly controversial. It is still challenging to balance the risks of side effects in the visual field against the uncertain effectiveness of the treatment. This paper delves into the pathogenesis of neovascular glaucoma to understand the development of therapeutic approaches. By taking into account various assessment criteria of central retinal vein occlusion and neovascular glaucoma over the years, combining functional tests and morphological tests provides the most accurate and rigorous solution. The age of patients, the extent, location, and duration of retinal ischemia are the primary factors that affect the severity and extent of ischemic central retinal vein occlusion and induce serious complications. From the perspective of prevention and treatment, the ischemic index is closely related to the development of neovascularization. The paper provides essential insights into the mechanism, efficacy, complications, and optimal timing of pan-retinal photocoagulation. Comparing the treatment effects of pan-retinal photocoagulation and intravitreal anti-VEGF injections, we suggest a combination of both treatments to explore effective treatment with fewer side effects in the long term. This article details the debate on the above issues and explores ideas for the clinical diagnosis and preventive treatment of neovascular glaucoma that results from ischemic central retinal vein occlusion.

Central retinal vein occlusion in young population: risk factors and outcomes

Objective

To evaluate the risk factors and outcomes of central retinal vein occlusion (CRVO) in young patients (< 40 years).

Methods

In this retrospective monocentric case series, we included young patients (<40 years) with CRVO. Patients’ medical files were analyzed focusing on demographic characteristics, suspected risk factors, ophthalmic work-up, visual acuity (VA), treatment, and outcomes.

Results

A total of 54 eyes of 52 patients were included. Central retinal vein occlusion was considered idiopathic in 13 patients (25%). The main risk factors identified were ocular hypertension (20.4%), inflammation (20.4%), high blood pressure (14.8%), and coagulation abnormality (11.1%). Final VA was lower in patients with high blood pressure and inflammation when compared to patients with no risk factor (p = 0.03 and 0.04, respectively). Intravitreal injections were needed in 23 eyes (42.6%) and 19 eyes (35.2%) received panretinal photocoagulation treatment.

Conclusion

Central retinal vein occlusion is frequently associated with risk factors in young patients (75% of patients). In addition to the usual factors found in older patients, such as ocular hypertension and high blood pressure, coagulation abnormality and inflammation were also among the risk factors identified. Young patients with CRVO should be evaluated for the presence of risk factors and patients with high blood pressure or inflammatory findings should be followed carefully since they have a worse outcome.

Prognostic Factor Study of Macular Edema Recurrence in Retinal Vein Occlusion after Conbercept Treatment: A Post Hoc Analysis of the FALCON Study

Objective

The study was aimed at exploring the potential predictive factors associated with the recurrence of macular edema (ME) secondary to vein occlusion (RVO) after intravitreal antivascular endothelial growth factor (VEGF) loading treatment in the FALCON study.

Methods

This is a post hoc analysis of 30 patients with central RVO and 30 patients with branch RVO. All patients received a monthly administration of intravitreal conbercept during the 3-month loading phase and pro re nata (PRN) treatment during the 6-month follow-up period. Based on the recurrence of ME at the first follow-up visit, patients were classified into the recurrence group or nonrecurrence group. The primary endpoint was to explore the risk factors for recurrence among baseline characteristics, fluorescein angiography (FA) patterns, and optical coherence tomography (OCT).

Results

In general, 38 patients (64.4%) experienced ME recurrence at the first follow-up visit (3 months), regardless of disease type (p = 0.32). Significant improvements in VA were noted in both the nonrecurrence and recurrence groups (p < 0.001), however, without significant between-group differences (p = 0.1). A significant reduction in CRT in both groups (p < 0.001) was identified, and patients without recurrence showed a greater reduction in CRT compared with those with recurrence (p < 0.001). In addition, logistic regression analyses indicated the corrections of ME recurrence with baseline macular volume and the disruption of the outer limiting membrane at the fovea.

Conclusion

This study suggested that OCT parameters, including baseline macular volume and outer limiting membrane disruption, and reduction in CRT after loading therapy were more predictive of ME recurrence than FA patterns or visual changes following conbercept loading therapy.

Assessment of image quality on color fundus retinal images using the automatic retinal image analysis

Image quality assessment is essential for retinopathy detection on color fundus retinal image. However, most studies focused on the classification of good and poor quality without considering the different types of poor quality. This study developed an automatic retinal image analysis (ARIA) method, incorporating transfer net ResNet50 deep network with the automatic features generation approach to automatically assess image quality, and distinguish eye-abnormality-associated-poor-quality from artefact-associated-poor-quality on color fundus retinal images. A total of 2434 retinal images, including 1439 good quality and 995 poor quality (483 eye-abnormality-associated-poor-quality and 512 artefact-associated-poor-quality), were used for training, testing, and 10-ford cross-validation. We also analyzed the external validation with the clinical diagnosis of eye abnormality as the reference standard to evaluate the performance of the method. The sensitivity, specificity, and accuracy for testing good quality against poor quality were 98.0%, 99.1%, and 98.6%, and for differentiating between eye-abnormality-associated-poor-quality and artefact-associated-poor-quality were 92.2%, 93.8%, and 93.0%, respectively. In external validation, our method achieved an area under the ROC curve of 0.997 for the overall quality classification and 0.915 for the classification of two types of poor quality. The proposed approach, ARIA, showed good performance in testing, 10-fold cross validation and external validation. This study provides a novel angle for image quality screening based on the different poor quality types and corresponding dealing methods. It suggested that the ARIA can be used as a screening tool in the preliminary stage of retinopathy grading by telemedicine or artificial intelligence analysis.

Review: The Development of Risk Factors and Cytokines in Retinal Vein Occlusion

Retinal vein occlusion (RVO) is the second most prevalent retinal disease. Despite this, the pathogenic mechanisms and risk factors are not entirely clear. In this article, we review recent publications on the classification, pathogenesis, risk factors, ischemic changes, cytokines, and vital complications of RVO. Risk factors and cytokines are important for exploring the mechanisms and new treatment targets. Furthermore, risk factors are interrelated, making RVO mechanisms more complex. Cytokines act as powerful mediators of pathological conditions, such as inflammation, neovascularization, and macular edema. This review aims to summarize the updated knowledge on risk factors, cytokines of RVO and signaling in order to provide valuable insight on managing the disease.

A Review of Intraocular Biomolecules in Retinal Vein Occlusion: Toward Potential Biomarkers for Companion Diagnostics

Retinal vein occlusion (RVO) is one of the most common retinal vascular diseases. The pathogenesis of RVO is multifactorial and involves a complex interplay among a variety of vascular and inflammatory mediators. Many cytokines, chemokines, growth factors, and cell adhesion molecules have been reported to be implicated. Treatments for RVO are directed at the management of underlying risk factors and vision-threatening complications, including macula edema (ME) and neovascularization. Intravitreal anti-VEGF agents are currently considered as the first-line treatment for ME secondary to RVO (RVO-ME), but a substantial proportion of patients responded insufficiently to anti-VEGF agents. Since RVO-ME refractory to anti-VEGF agents generally responds to corticosteroids and its visual outcome is negatively correlated to disease duration, prediction of treatment response at baseline in RVO-ME may significantly improve both cost-effectiveness and visual prognosis. Several bioactive molecules in the aqueous humor were found to be associated with disease status in RVO. This review aims to present a comprehensive review of intraocular biomolecules reported in RVO, including VEGF, IL-6, IL-8, MCP-1, sICAM-1, IL-12, IL-13, sVEGFR-1, sVEGFR-2, PDGF-AA, etc., highlighting their association with disease severity and/or phenotype, and their potential roles in prognostic prediction and treatment selection. Some of these molecules may serve as biomarkers for aqueous humor-based companion diagnostics for the treatment of RVO in the future.

Phenotyping of retinal neovascularization in ischemic retinal vein occlusion using wide field OCT angiography

BACKGROUND/OBJECTIVES

Abnormal retinal neovascularization caused by ischemic retinal vein occlusion (RVO) is a frequent cause of visually significant vitreous hemorrhage. The early detection of new vessels may be challenging and often requires the use of invasive tests such as fundus fluorescein angiography (FA). We demonstrate the use of wide-field optical coherence tomography angiography (WF-OCTA) in the detection and characterization of neovascularization secondary to ischemic RVO.

SUBJECTS/METHODS

We conducted a retrospective observational case series of patients diagnosed with ischemic RVO between August 2018 and March 2019, who underwent WF-SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec). We performed real-life montage imaging, covering the involved area and compared the findings of WF-SS-OCTA to standard clinical examination and when available, ultrawide-field fluorescein angiography (UWF-FA, Optos 200TX).

RESULTS

In the included 39 eyes with ischemic RVO, neovascularization elsewhere (NVE) was encountered in 16 of 39 eyes (41%) on WF-OCTA and were characterized as sea-fan type vessels and nodular type vessels, based on their appearance and localization. NVE was identified in 4/39 eyes on standard clinical examination, equating to a detection rate of 10.3%. All were of a sea-fan morphology. In one case, NVE found on WF-OCTA was not observed on UWF-FA, which was a nodular type. Neovascularization of the disc (NVD) was detected in one eye.

CONCLUSIONS

WF-OCTA may become a useful noninvasive tool in the detection of neovascularization in patients with ischemic RVO. Furthermore, the characterization of different morphologies of neovascularization detected by WF-OCTA could be of clinical relevance.

Continuous wavelet transform analysis of ERG in patients with diabetic retinopathy

PURPOSE

Diabetic retinopathy (DR) is one of the leading causes of blindness worldwide. Non-proliferative diabetic retinopathy (NPDR) is a stage of the disease that contains morphological and functional disruption of the retinal vasculature and dysfunction of retinal neurons. This study aimed to compare time and time-frequency-domain analysis in the evaluation of electroretinograms (ERGs) in subjects with NPDR.

METHOD

The ERG responses were recorded in 16 eyes from 12 patients with NPDR and 24 eyes from 12 healthy subjects as the control group. The implicit time, amplitude, and time-frequency-domain parameters of photopic and scotopic ERGs were analyzed.

RESULTS

The implicit times of b-waves in the dark-adapted 10.0 (P = 0.0513) and light-adapted 3.0 (P = 0.0414) were significantly increased in the NPDR group. The amplitudes of a- and b-wave showed a significantly decreased dark-adapted 10.0 (P = 0.0212; P = 0.0133) and light-adapted 3.0 (P = 0.0517; P = 0.0021) ERG of the NPDR group. The Cohen's d effect size had higher values in the amplitude of dark-adapted 10.0 b-wave (|d|= 1.8058) and amplitude of light-adapted 3.0 b-wave (|d|= 1.9662). The CWT results showed that the frequency ranges of the dominant components in dark-adapted 10.0 and light-adapted 3.0 ERG were decreased in the NPDR group compared to the healthy group (P < 0.05). The times associated with the NDPR group's dominant components were increased compared to normal eyes in both dark-adapted 10.0 and light-adapted 3.0 ERG (P < 0.05). All Cohen's d effect sizes of the implicit times and dominant frequency components were on a large scale (|d|> 1).

CONCLUSION

These findings suggest that the time and time-frequency parameters of both photopic and scotopic ERGs can be good indicators for DR. However, time-frequency-domain analysis could present more information might be helpful in the assessment of the DR severity.

Results from the Population-Based Gutenberg Health Study Revealing Four Altered Autoantibodies in Retinal Vein Occlusion Patients

Purpose

Retinal vein occlusion (RVO) is the second most common retinal vascular disease and a major cause of visual impairment. In this study, we aimed to observe whether RVO cases have different antibody profiles as a new potential risk factor and whether a conversion of retinal vein occlusion (RVO) to neovascular glaucoma (NVG), one of the major complications, is occurring within a 5-year timeframe.

Methods

We performed a nested case-control study (1 : 4) within the Gutenberg Health Study (GHS), a population-based, prospective cohort study in the Rhine-Main Region of Germany including 15,010 participants. RVO subjects (n = 59) were identified by grading of fundus photographs. Optic nerves of RVO subjects and age- and sex-matched controls (n = 229) at baseline and their follow-up examination after 5 years were analyzed for glaucomatous alterations. Of all RVO subjects and controls, serum autoantibody profiles were measured using in-house manufactured antigen-antibody microarrays.

Results

Of the 59 RVO patients, 3 patients (5%) showed glaucomatous optic disc alterations at baseline, whereas no new glaucoma case was detected at 5-year follow-up. Four of the autoantibodies measured (against dermcidin, neurotrophin-3, superoxide dismutase 1, and signal recognition particle 14 kDa protein) were significantly increased in the serum of RVO patients (p < 0.001). Multivariable conditional logistic regression analysis showed that 3 of these 4 antibodies were independent of cardiovascular risk factors.

Conclusions

We found several autoantibodies associated with RVO, targeting proteins and structures possibly involved in RVO pathogenesis.

Altered intrinsic functional connectivity of the primary visual cortex in patients with retinal vein occlusion: a resting-state fMRI study

Background

To investigate the differences of spontaneous functional connectivity (FC) of the primary visual cortex (V1) between patients with retinal vein occlusion (RVO) and healthy controls (HCs) using resting-state functional magnetic resonance imaging (rs-fMRI) data.

Methods

Twenty-one patients with RVO in total (11 males, 10 females) and 21 HCs similarly analogue in age and sex background were enrolled and inspected with rs-fMRI. The difference in FC of V1 between two groups were compared using two-sample t-test. We used the receiver operating characteristic (ROC) curve to distinguish average FC values of RVO subjects from HCs. The interrelationships between FC signals of specific cerebrum regions and clinical features in RVOs were assessed with the Pearson's correlation analysis.

Results

Compared with HCs, FC in left V1 and right middle frontal gyrus increased significantly in RVO group, while FC in left V1 and right cuneus decreased significantly. Meanwhile, patients with RVO presented increased FC between the right V1 and right middle frontal gyrus, right superior frontal gyrus, but declining FC between right V1 and right cuneus. The mean FC value between the right cuneus and the right V1 as well as the left V1 were negative correlated with the foveal thickness of RVO patients. ROC curve analysis of each brain regions showed the accuracy of AUC was excellent.

Conclusions

RVO involves aberrant FC in V1 in different brain areas including visual-related and cognitive-related region, which might assist to unveil the underlying neural mechanisms of impaired visual function in RVO.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY CAN IMPROVE DIABETIC RETINOPATHY SCORE WITHOUT CHANGE IN RETINAL PERFUSION

After three intravitreal anti–vascular endothelial growth factor injections, the severity of diabetic retinopathy on color fundus photographs improved, whereas no reperfusion occurred in the nonperfusion areas assessed on ultra–wide-field fluorescein angiography.

Purpose:

To compare the changes in retinal perfusion on ultra–wide-field fluorescein angiography with the changes in diabetic retinopathy lesions observed on ultra–wide-field fundus color photographs after 3 monthly anti–vascular endothelial growth factor injections.

Methods:

Retrospective interventional cohort study analyzing the files of 14 patients with DR (18 eyes). UWF color photos and FA were analyzed at baseline (M0) and 1 month after the third anti-VEGF injection (M3). The main outcomes included the count of the number of red dots (microaneurysms, hemorrhages) and assessment of DR severity score (DRSS); the analysis of non-perfusion areas and disappearance or reappearance of arterioles or venules in the non-perfusion areas on FA.

Results:

Eighteen eyes of 14 diabetic patients, with mean age of 63 ± 5 years, were included. The DRSS score improved by at least one stage in 11/18 (61%) eyes. The mean number of red dots significantly decreased at M3 (n = 80 ± 85) compared with M0 (n = 139 ± 130) (P < 0.0001). No reperfusion of arterioles or venules was observed in or around nonperfusion areas.

Conclusion:

After anti–vascular endothelial growth factor injections, the improvement in the DRSS score based on color fundus photographs can occur without retinal reperfusion on ultra–wide-field fluorescein angiography.

Diabetes mellitus as a risk factor for retinal vein occlusion: A meta-analysis

Retinal vein occlusion (RVO) is the second most common etiology for vision loss. There is contrasting evidence on the association between diabetes mellitus (DM) and the risk of RVO. We performed a meta-analysis of published articles before October 31, 2019, to estimate a pooled odds ratio for the association between DM and RVO, including central and branch RVO by a fixed or random effects model. We identified 37 publications from 38 studies (1 publication was from 2 studies), published between 1985 and 2019. In total, 148,654 cases and 23,768,820 controls were included in this meta-analysis. The results of pooled analysis for all 37 publications (or 38 studies) showed a significant association between DM and the risk of RVO (OR = 1.68, 95% CI: 1.43-1.99). Subgroup analysis indicated that DM was significantly associated with CRVO (OR = 1.98, 95% CI: 1.29-3.03, I = 67.9%), but not significantly associated with BRVO (OR = 1.22, 95% CI: 0.95-1.56, I = 64.1%). In conclusion, the result of present meta-analysis suggested that DM is a risk factor for RVO. More well-designed studies on the relationship between RVO and DM should be undertaken in the future.

Predictors of Neovascular Glaucoma in Central Retinal Vein Occlusion

PURPOSE

To determine the risk factors for development of neovascular glaucoma (NVG) in patients after an acute central retinal vein occlusion (CRVO).

DESIGN

Retrospective cohort study.

METHODS

Review of medical records of 646 patients with a diagnosis of CRVO between 2013 and 2017 at the Bascom Palmer Eye Institute.

INCLUSION CRITERIA

(1) CRVO onset to presentation <90 days; (2) absence of anterior segment neovascularization on presentation; (3) no intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection before presentation. Patients meeting inclusion criteria were screened for potential risk factors for development of NVG. Risk of developing NVG was assessed with Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Thirteen of 98 patients (13%) who met inclusion criteria developed NVG. The mean adjusted time to NVG diagnosis from onset of CRVO-related symptoms was 212 days. Patients presenting with a worse initial visual acuity (P = .034), a relative afferent pupillary defect (RAPD) (P = .002), or a history of systemic hypertension (P = .026) had an increased risk of NVG compared to those who did not. Age, body mass index, history of glaucoma, history of diabetes, and central retinal thickness were not significantly associated with development of NVG.

CONCLUSIONS

Risk factors for NVG development included history of systemic hypertension, worse visual acuity on presentation, and RAPD on presentation. Patients presenting with these findings should be followed at closer intervals and informed of the greater risk for neovascularization. Intravitreal anti-VEGF therapy delayed but did not prevent NVG.

Comparison of the efficacy and safety of drug therapies for macular edema secondary to central retinal vein occlusion

OBJECTIVES

To evaluate the efficacy and safety of anti-vascular endothelial growth factor (VEGF) agents and corticosteroids for the treatment of macular oedema (ME) secondary to central retinal vein occlusion (CRVO).

DESIGN

Systematic review and network meta-analysis.

PARTICIPANTS

Patients from previously reported randomised controlled trials (RCTs) comparing anti-VEGF and corticosteroids for the treatment of ME secondary to CRVO.

METHODS

Literature searches were conducted using PubMed, Medline, Embase, Cochrane Library and clinicaltrials.gov until March 2017. Therapeutic effects were estimated using the proportions of patients gaining/losing ≥15 letters, best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Treatment safety was estimated using the proportions of adverse events, namely increased intraocular pressure (IOP), cataracts, vitreous haemorrhage (VH) and retinal tear. The software ADDIS (V.1.16.8) was used for analysis. Treatment effect and safety of different drugs could be ranked based on simulation.

RESULTS

Eleven RCTs comprising 2060 patients were identified. Regarding patients gaining ≥15 letters, aflibercept and ranibizumab were significantly more effective than sham/placebo at 6 months. Regarding patients losing ≥15 letters at 6 months, ranibizumab showed significant improvement compared with dexamethasone. Aflibercept, bevacizumab or ranibizumab showed greater improvements in BCVA than sham/placebo at 6 months. Intravitreal ranibizumab injection demonstrated greater CRT reduction than both sham and dexamethasone did. Dexamethasone had a higher risk of increased IOP than aflibercept and ranibizumab. Ranibizumab demonstrated a greater risk of cataracts than dexamethasone. Aflibercept and ranibizumab demonstrated low incidence of VH and retinal tear, respectively. Aflibercept had a slight advantage over ranibizumab as assessed by benefit-risk analysis.

CONCLUSIONS

Anti-VEGF agents have advantages in the treatment of ME secondary to CRVO. Aflibercept and ranibizumab showed marked BCVA improvement and CRT reduction. Aflibercept may have a slight advantage over ranibizumab. The results of this study can serve as a reference for clinicians to provide patient-tailored treatment.

PROSPERO REGISTRATION NUMBER

CRD42017064076.

Mystery of Retinal Vein Occlusion: Vasoactivity of the Vein and Possible Involvement of Endothelin-1

Retinal vein occlusion (RVO) is a common vascular disease of retina; however, the pathomechanism leading to RVO is not yet clear. In general, increasing age, hypertension, arteriosclerosis, diabetes mellitus, dyslipidemia, cardiovascular disorder, and cerebral stroke are systemic risk factors of RVO. However, RVO often occur in the unilateral eye and sometimes develop in young subjects who have no arteriosclerosis. In addition, RVO show different variations on the degrees of severity; some RVO are resolved without any treatment and others develop vision-threatening complications such as macular edema, combined retinal artery occlusion, vitreous hemorrhage, and glaucoma. Clinical conditions leading to RVO are still open to question. In this review, we discuss how to treat RVO in practice by presenting some RVO cases. We also deliver possible pathomechanisms of RVO through our clinical experience and animal experiments.

[Current approach and the role of laser photocoagulation in the treatment of retinal vein occlusions]

Despite the emergence of new approaches in the treatment of retinal vein thrombosis and post-thrombotic complications, namely, intravitreal pharmacotherapy and surgical treatment, laser photocoagulation continues to play a significant role in the management of patients with this pathology. Although the method of laser photocoagulation has been used for quite a long time, different views exist on its indications and execution in specific clinical situations. At that, not all opinions regarding the use of laser photocoagulation in thrombosis are based on convincing clinical studies. The aim of this work was to summarize current literature data on the use of laser photocoagulation in the integrated treatment of retinal vein occlusions and, also, to show which aspects of the treatment of thromboses can be considered well-established and reasonable and which remain a subject of debate.

Neovascularization of the iris in retinoschisis

Purpose

To report the association of rubeosis iridis with chronic bullous degenerative peripheral retinoschisis.

Observations

A 63-year-old female presented with acute hyphema and neovascularization of the iris in association with elevated intraocular pressure. Posterior segment examination including imaging revealed no vascular occlusion as a potential cause. However, large, peripheral bullous retinoschisis was noted in the right eye. No nonperfusion aside from that seen within the schism detachment, or neovascularization of the retina on wide-field fundus photography or fluorescein angiography was noted. Bullous retinoschisis was also found in the left eye. The patient was treated conservatively with prednisolone acetate and timolol eye drops.

Conclusions and importance

Chronic bullous retinoschisis can be associated with anterior segment neovascularization such as rubeosis iridis, presumably due to non-perfusion within the retinoschisis cavity.

Anterior chamber depth and angle-closure glaucoma after central retinal vein occlusion

Background

The purpose of this study was to report the anterior chamber (AC) depth and the attack of angle-closure glaucoma (ACG) in eyes with the recent onset of central retinal vein occlusion (CRVO).

Methods

This retrospective case series included 24 patients with recent onset of CRVO (within one month of attack) from July 2001 to December 2002. The mean follow-up period of the patients was 46 months (range: 3 to 92 months). AC depth was measured using an ultrasound biomicroscopy. Clinical data, including systemic disorders, intraocular pressure, and visual outcomes were recorded. The main outcome measures were AC depth in the diseased eye and the fellow eye of the same patient and the attack of ACG after CRVO.

Results

The mean AC depth in the diseased eyes was significantly shallower than in the unaffected fellow eyes (2.43 ± 0.45 mm vs. 2.55 ± 0.46 mm; p < 0.001). Four patients (17 %) developed ACG after the onset of CRVO within one month of the CRVO attack. In these four patients, the mean AC depth in the diseased eyes was 1.91 ± 0.21 mm, which was much shallower than the eyes without ACG attack (2.53 ± 0.40 mm).

Conclusions

AC depth is significantly shallower following the onset of CRVO. ACG can occur in patients after the onset of CRVO.

Outcomes of 23-Gauge Vitrectomy Combined with Phacoemulsification, Panretinal Photocoagulation, and Trabeculectomy without Use of Anti-VEGF Agents for Neovascular Glaucoma with Vitreous Hemorrhage

Purpose. To evaluate the outcomes of 23-gauge vitrectomy combined with phacoemulsification, PRP and trabeculectomy without use of anti-VEGF-agents for NVG. Methods. Eighteen eyes of 18 patients with NVG underwent 23-gauge vitrectomy combined with phacoemulsification, PRP and trabeculectomy without use of anti-VEGF agents. The preoperative BCVA ranged from light perception to 0.2. The preoperative IOP ranged from 38 mmHg to 64 mmHg with a mean of 54 ± 8 mmHg. The average follow-up time was 14.5 ± 3 months with a range from 11 to 24 months. Results. The postoperative VA increased in 14 eyes and was stable in 4 eyes at the final follow-up. The mean IOP was 12 ± 3 mmHg at postoperative day 1. The mean IOP was 15 ± 2 mmHg, 16 ± 3 mmHg, 23 ± 5 mmHg, 28 ± 4 mmHg, 22 ± 5 mmHg, 17 ± 3 mmHg, and 19 ± 4 mmHg at postoperative days 2 and 3, 1, 2, 3, and 12 weeks, and 1 year postoperatively, respectively, with a range from 10 to 30 mmHg at the final follow-up time point of one year. The IOP was significantly lower than the preoperative one 12 weeks postoperatively (p < 0.05). Conclusion. 23-gauge vitrectomy combined with phacoemulsification, PRP, and trabeculectomy without use of anti-VEGF-agents is a safe and effective method in treating NVG.

En-face optical coherence tomography angiography of neovascularization elsewhere in hemicentral retinal vein occlusion

Purpose

To evaluate how the growth of neovascularization elsewhere (NVE) was delineated in an eye with hemicentral retinal vein occlusion (CRVO) using optical coherence tomography (OCT) angiography.

Patients and methods

We examined a 64-year-old man diagnosed with hemi-CRVO. The area around the occluded vein was scanned using a spectral-domain OCT device (RTVue XR Avanti). Blood flow was detected using the split-spectrum amplitude-decorrelation angiography (SSADA) algorithm. Color fundus photography, fluorescein angiography (FA), and OCT angiography examinations were performed at the first visit and at 3 and 6 months postpresentation.

Results

At the first visit, FA revealed delayed retinal venous filling and extensive areas of capillary nonperfusion. The patient underwent a trial of intravitreal ranibizumab injection (0.5 mg/0.05 mL) for the treatment of macular edema. At 3 months postpresentation, there was no NVE around the occluded vein in the en-face SSADA image, but at 6 months, NVE appeared on the occluded veins. The en-face SSADA image showed the NVE structure in the fibrovascular membrane on the occluded vein more clearly than FA images.

Conclusion

OCT angiography clearly visualized the sprouting of NVE in an eye with hemi-CRVO. New findings of the vascular structure of NVE in hemi-CRVO were revealed using the en-face SSADA algorithm.

Drug treatment of macular oedema secondary to central retinal vein occlusion: a network meta-analysis

OBJECTIVE

To indirectly compare aflibercept, bevacizumab, dexamethasone, ranibizumab and triamcinolone for treatment of macular oedema secondary to central retinal vein occlusion using a network meta-analysis (NMA).

DESIGN NMA DATA SOURCES

The following databases were searched from January 2005 to March 2013: MEDLINE, MEDLINE In-process, EMBASE; CDSR, DARE, HTA, NHSEED, CENTRAL; Science Citation Index and Conference Proceedings Citation Index-Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Only randomised controlled trials assessing patients with macular oedema secondary to central retinal vein occlusion were included. Studies had to report either proportions of patients gaining ≥3 lines, losing ≥3 lines, or the mean change in best corrected visual acuity. Two authors screened titles and abstracts, extracted data and undertook risk of bias assessment. Bayesian NMA was used to compare the different interventions.

RESULTS

Seven studies, assessing five drugs, were judged to be sufficiently comparable for inclusion in the NMA. For the proportions of patients gaining ≥3 lines, triamcinolone 4 mg, ranibizumab 0.5 mg, bevacizumab 1.25 mg and aflibercept 2 mg had a higher probability of being more effective than sham and dexamethasone. A smaller proportion of patients treated with triamcinolone 4 mg, ranibizumab 0.5 mg or aflibercept 2 mg lost ≥3 lines of vision compared to those treated with sham. Patients treated with triamcinolone 4 mg, ranibizumab 0.5 mg, bevacizumab 1.25 mg and aflibercept 2 mg had a higher probability of improvement in the mean best corrected visual acuity compared to those treated with sham injections.

CONCLUSIONS

We found no evidence of differences between ranibizumab, aflibercept, bevacizumab and triamcinolone for improving vision. The antivascular endothelial growth factors (VEGFs) are likely to be favoured because they are not associated with steroid-induced cataract formation. Aflibercept may be preferred by clinicians because it might require fewer injections.

SYSTEMATIC REVIEW REGISTRATION

Not registered.

Anti-vascular endothelial growth factor for macular oedema secondary to central retinal vein occlusion

BACKGROUND

Central retinal vein occlusion (CRVO) is a relatively common retinal vascular disorder in which macular oedema may develop, with a consequent reduction in visual acuity. Until recently there has been no treatment of proven benefit, but growing evidence supports the use of anti-vascular endothelial growth factor (anti-VEGF) agents.

OBJECTIVES

To investigate the effectiveness and safety of anti-VEGF therapies for the treatment of macular oedema secondary to CRVO.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 10), Ovid MEDLINE (January 1950 to October 2013), EMBASE (January 1980 to October 2013), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to October 2013), OpenGrey, OpenSIGLE (January 1950 to October 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and Web of Science Conference Proceedings Citation Index-Science (CPCI-S). There were no language or date restrictions in the electronic search for trials. The electronic databases and clinical trials registers were last searched on 29th October 2013.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared intravitreal anti-VEGF agents of any dose or duration to sham injection or no treatment. We focused on studies that included individuals of any age or gender and a minimum of six months follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The primary outcome was the proportion of participants with a gain in best-corrected visual acuity (BCVA) from baseline of greater than or equal to 15 letters (3 lines) on the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Secondary outcomes included the proportion of participants with a loss of 15 letters or more of BCVA, the mean change from baseline BCVA, the mean change in central retinal thickness (CRT), the number and type of complications or adverse outcomes, and the number of additional interventions administered. Where available, we also presented quality of life and economic data.

MAIN RESULTS

We found six RCTs that met the inclusion criteria after independent and duplicate review of the search results. These RCTs included 937 participants and compared outcomes at six months to sham injection for four anti-VEGF agents: aflibercept (VEGF Trap-Eye, Eylea), bevacizumab (Avastin), pegaptanib sodium (Macugen) and ranibizumab (Lucentis). Three trials were conducted in Norway, Sweden and the USA, and three trials were multicentre, one including centres in the USA, Canada, India, Israel, Argentina and Columbia, a second including centres in the USA, Australia, France, Germany, Israel, and Spain, and a third including centres in Austria, France, Germany, Hungary, Italy, Latvia, Australia, Japan, Singapore and South Korea. We performed meta-analysis on three key visual outcomes, using data from up to six trials. High-quality evidence from six trials revealed that participants receiving intravitreal anti-VEGF treatment were 2.71 times more likely to gain at least 15 letters of visual acuity at six months compared to participants treated with sham injections (risk ratio (RR) 2.71; 95% confidence intervals (CI) 2.10 to 3.49). High-quality evidence from five trials suggested anti-VEGF treatment was associated with an 80% lower risk of losing at least 15 letters of visual acuity at six months compared to sham injection (RR 0.20; 95% CI 0.12 to 0.34). Moderate-quality evidence from three trials (481 participants) revealed that the mean reduction from baseline to six months in central retinal thickness was 267.4 µm (95% CI 211.4 µm to 323.4 µm) greater in participants treated with anti-VEGF than in participants treated with sham. The meta-analyses demonstrate that treatment with anti-VEGF is associated with a clinically meaningful gain in vision at six months. One trial demonstrated sustained benefit at 12 months compared to sham. No significant ocular or systemic safety concerns were identified in this time period.

AUTHORS' CONCLUSIONS

Compared to no treatment, repeated intravitreal injection of anti-VEGF agents in eyes with CRVO macular oedema improved visual outcomes at six months. All agents were relatively well tolerated with a low incidence of adverse effects in the short term. Future trials should address the relative efficacy and safety of the anti-VEGF agents and other treatments, including intravitreal corticosteroids, for longer-term outcomes.

The effect of antivascular endothelial growth factor therapy on the development of neovascular glaucoma after central retinal vein occlusion: a retrospective analysis

Purpose. Ischemic central retinal vein occlusion (CRVO) eyes are at high risk of developing neovascular glaucoma (NVG). Our purpose is to investigate the effect of anti-VEGF therapy for macular edema after CRVO on the development of neovascular glaucoma (NVG) in ischemic CRVO eyes. Methods. This is a retrospective case series of 44 eyes from 44 patients with CRVO treated with anti-VEGF therapy for macular edema. The primary outcome was the development of NVG. Results. Of the 44 eyes, 14 eyes had ischemic CRVO, and 30 eyes had nonischemic CRVO. Nonischemic eyes received a mean of 8.4 anti-VEGF doses, over mean follow-up of 24 months. One nonischemic eye (3.3%) developed NVD but not NVG. The 14 ischemic eyes received a mean of 5.6 anti-VEGF doses, with mean follow-up of 23 months. Of these 14 ischemic eyes, two eyes (14%) developed iris neovascularization and 3 eyes (21%) developed posterior neovascularization. Three of these 5 eyes with neovascularization progressed to NVG, at 19.7 months after symptom onset, on average. Conclusion. Anti-VEGF therapy for macular edema may delay, but does not prevent, the development of ocular NV in ischemic CRVO. Significant risk of NVG still exists for ischemic CRVO eyes.

Treatments for macular oedema following central retinal vein occlusion: systematic review

OBJECTIVES

To review systematically the randomised controlled trial (RCT) evidence for treatment of macular oedema due to central retinal vein occlusion (CRVO).

DATA SOURCES

MEDLINE, EMBASE, CDSR, DARE, HTA, NHSEED, CENTRAL and meeting abstracts (January 2005 to March 2013).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

RCTs with at least 12 months of follow-up assessing pharmacological treatments for CRVO were included with no language restrictions.

STUDY APPRAISAL AND SYNTHESIS METHODS

2 authors screened titles and abstracts and conducted data extracted and Cochrane risk of bias assessment. Meta-analysis was not possible due to lack of comparable studies.

RESULTS

8 studies (35 articles, 1714 eyes) were included, assessing aflibercept (n=2), triamcinolone (n=2), bevacizumab (n=1), pegaptanib (n=1), dexamethasone (n=1) and ranibizumab (n=1). In general, bevacizumab, ranibizumab, aflibercept and triamcinolone resulted in clinically significant increases in the proportion of participants with an improvement in visual acuity of ≥15 letters, with 40-60% gaining ≥15 letters on active drugs, compared to 12-28% with sham. Results for pegaptanib and dexamethasone were mixed. Steroids were associated with cataract formation and increased intraocular pressure. No overall increase in adverse events was found with bevacizumab, ranibizumab, aflibercept or pegaptanib compared with control. Quality of life was poorly reported. All studies had a low or unclear risk of bias.

LIMITATIONS

All studies evaluated a relatively short primary follow-up (1 year or less). Most had an unmasked extension phase. There was no head-to-head evidence. The majority of participants included had non-ischaemic CRVO.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Bevacizumab, ranibizumab, aflibercept and triamcinolone appear to be effective in treating macular oedema secondary to CRVO. Long-term data on effectiveness and safety are needed. Head-to-head trials and research to identify 'responders' is needed to help clinicians make the right choices for their patients. Research aimed to improve sight in people with ischaemic CRVO is required.

Efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review

BACKGROUND

Intravitreal agents have replaced observation in macular edema in central (CRVO) and grid laser photocoagulation in branch retinal vein occlusion (BRVO). We conducted a systematic review to evaluate efficacy and safety outcomes of intravitreal therapies for macular edema in CRVO and BRVO.

METHODS AND FINDINGS

MEDLINE, Embase, and the Cochrane Library were systematically searched for RCTs with no limitations of language and year of publication. 11 RCTs investigating anti-VEGF agents (ranibizumab, bevacizumab, aflibercept) and steroids (triamcinolone, dexamethasone implant) with a minimum follow-up of 1 year were evaluated.

EFFICACY CRVO

Greatest gain in visual acuity after 12 months was observed both under aflibercept 2 mg: +16.2 letters (8.5 injections), and under bevacizumab 1.25 mg: +16.1 letters (8 injections). Ranibizumab 0.5 mg improved vision by +13.9 letters (8.8 injections). Triamcinolone 1 mg and 4 mg stabilized visual acuity at a lower injection frequency (-1.2 letters, 2 injections).

BRVO

Ranibizumab 0.5 mg resulted in a visual acuity gain of +18.3 letters (8.4 injections). The effect of dexamethasone implant was transient after 1.9 implants in both indications.

SAFETY

Serious ocular adverse events were rare, e.g., endophthalmitis occurred in 0.0-0.9%. Major differences were found in an indirect comparison between steroids and anti-VEGF agents for cataract progression (19.8-35.0% vs. 0.9-7.0%) and in required treatment of increased intraocular pressure (7.0-41.0% vs. none). No major differences were identified in systemic adverse events.

CONCLUSIONS

Anti-VEGF agents result in a promising gain of visual acuity, but require a high injection frequency. Dexamethasone implant might be an alternative, but comparison is impaired as the effect is temporary and it has not yet been tested in PRN regimen. The ocular risk profile seems to be favorable for anti-VEGF agents in comparison to steroids. Because comparative data from head-to-head trials are missing currently, clinicians and patients should carefully weigh the benefit-harm ratio.

Surgical management of fibrotic encapsulation of the fluocinolone acetonide implant in CAPN5-associated proliferative vitreoretinopathy

Objective

To review fibrosis of fluocinolone acetonide (FA) implants in subjects with CAPN5 autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV).

Methods

A retrospective case series was assembled from ADNIV patients in which there was fibrotic encapsulation of a fluocinolone acetonide implant. CAPN5 genotypes and surgical repair techniques were reviewed.

Results

Two eyes of two ADNIV patients developed a fibrotic capsule over the fluocinolone acetonide implant. Both patients had Stage IV disease. Patient A had a c.731T > C mutation in the CAPN5 gene and patient B had a c.728G > T mutation. The fibrotic membrane was surgically excised and the implant function was restored.

Conclusion

The exuberant fibrotic response in later stages of ADNIV may be resistant to local immunosuppression with steroids. Surgical excision of fibrotic membranes over FA implants can reestablish local steroid delivery in cases of severe proliferative vitreoretinopathy.

Inhibition of neovascularization but not fibrosis with the fluocinolone acetonide implant in autosomal dominant neovascular inflammatory vitreoretinopathy

OBJECTIVE To review the effect of the fluocinolone acetonide implant in subjects with autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), an inherited autoimmune uveitis. METHODS A retrospective case series was assembled from patients with ADNIV who received fluocinolone acetonide implants. Visual acuity and features of ADNIV, including inflammatory cells, neovascularization, fibrosis, and cystoid macular edema, were reviewed. RESULTS Nine eyes of 5 related patients with ADNIV with uncontrolled inflammation were reviewed. Follow-up ranged from 21.7 to 56.7 months. Visual acuity at implantation ranged from 20/40 to hand motion. Preoperatively, 8 eyes had vitreous cells (a ninth had diffuse vitreous hemorrhage). Eight eyes had cystoid macular edema, 7 had an epiretinal membrane, and 3 had retinal neovascularization. Following implantation, vitreous cells resolved in all eyes and neovascularization regressed or failed to develop. Central macular thickness improved in 4 eyes. During the postoperative course, however, visual acuity continued to deteriorate, with visual acuity at the most recent examination ranging from 20/60 to no light perception. There was also progressive intraocular fibrosis and phthisis in 1 case. Four eyes underwent cataract surgery. Six of the 7 eyes without previous glaucoma surgery had elevated intraocular pressure at some point, and 3 of these required glaucoma surgery. CONCLUSIONS The fluocinolone acetonide implant may inhibit specific features of ADNIV such as inflammatory cells and neovascularization but does not stabilize long-term vision, retinal thickening, or fibrosis. All eyes in this series required cataract extraction, and more than half required surgical intervention for glaucoma. Further studies may identify additional therapies and any benefit of earlier implantation.

A longitudinal analysis of risk factors associated with central retinal vein occlusion

PURPOSE

To identify risk factors associated with central retinal vein occlusion (CRVO) among a diverse group of patients throughout the United States.

DESIGN

Longitudinal cohort study.

PARTICIPANTS

All beneficiaries aged ≥ 55 years who were continuously enrolled in a managed care network for at least 2 years and who had ≥ 2 visits to an eye care provider from 2001 to 2009.

METHODS

Insurance billing codes were used to identify individuals with a newly diagnosed CRVO. Multivariable Cox regression was performed to determine the factors associated with CRVO development.

MAIN OUTCOME MEASURES

Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of being diagnosed with CRVO.

RESULTS

Of the 494 165 enrollees who met the study inclusion criteria, 1302 (0.26%) were diagnosed with CRVO over 5.4 (± 1.8) years. After adjustment for known confounders, blacks had a 58% increased risk of CRVO compared with whites (HR, 1.58; 95% CI, 1.25-1.99), and women had a 25% decreased risk of CRVO compared with men (HR, 0.75; 95% CI, 0.66-0.85). A diagnosis of stroke increased the hazard of CRVO by 44% (HR, 1.44; 95% CI, 1.23-1.68), and hypercoagulable state was associated with a 145% increased CRVO risk (HR, 2.45; 95% CI, 1.40-4.28). Individuals with end-organ damage from hypertension (HTN) or diabetes mellitus (DM) had a 92% (HR, 1.92; 95% CI, 1.52-2.42) and 53% (HR, 1.53; 95% CI, 1.28-1.84) increased risk of CRVO, respectively, relative to those without these conditions.

CONCLUSIONS

This study confirms that HTN and vascular diseases are important risk factors for CRVO. We also identify black race as being associated with CRVO, which was not well appreciated previously. Furthermore, we show that compared with patients without DM, individuals with end-organ damage from DM have a heightened risk of CRVO, whereas those with uncomplicated DM are not at increased risk of CRVO. This finding may provide a potential explanation for the conflicting reports in the literature on the association between CRVO and DM. Information from analyses such as this can be used to create a risk calculator to identify possible individuals at greatest risk for CRVO.